Provider Demographics
NPI:1619972338
Name:ANDRE, PHILIP GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:GORDON
Last Name:ANDRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11180 HWY 51 N.
Mailing Address - Street 2:STE 3
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004
Mailing Address - Country:US
Mailing Address - Phone:901-837-9910
Mailing Address - Fax:901-837-9914
Practice Address - Street 1:11180 HWY 51 N.
Practice Address - Street 2:STE 3
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004
Practice Address - Country:US
Practice Address - Phone:901-837-9910
Practice Address - Fax:901-837-9914
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39028174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3717404Medicaid
TN3325236Medicare ID - Type UnspecifiedMEDICARE #
TN3717404Medicaid